Clinical governance lead Dr Paul Twomey describes how a PCG initiative set up to develop local cancer guidelines also enables local cancer services to be reviewed

The North East Lincolnshire Clinical Development initiative was set up in response to the Calman–Hine guidance, to facilitate the development of local referral guidelines for patients with suspected cancer. As a local health community however, we used it as an opportunity to review the local service in a number of specific cancer areas.

Although Calman-Hine covers a wide range of cancer areas, the principal services reviewed within this initiative for 1999/2000 were the breast and colorectal cancer services. These areas were chosen because they were in the initial tranche of cancers included in the guidance.

Our medium- and long-term objectives are the development of care pathways incorporating all appropriate agencies, but principally primary and secondary care, to achieve the most effective local service.

Implementation of the guidance highlighted already significant capacity issues for both service areas. We hoped that the review process would lead to the development of systems that, if successful, would enable the appropriate development of these two cancer areas, and could be utilised for other cancer areas at a later date.

A local framework for the development of guidelines (care pathways) (see Figure 1,below) evolved and was supported by the local health community.

Figure 1: Local framework for development of guidelines (care pathways)

Step 1

Establish project team constituting clinicians from primary and secondary care with appropriate administrative and audit support.

Initial objectives of this group to develop a draft:

  • Clinical value*
  • Guideline
  • Referral proforma
Step 2

Obtain initial feedback from PCG Clinical Governance Committee regarding the above proposals. Our local clinical governance committee consists of GP leads from each of the seven primary healthcare teams within the PCG, nurse professional leads (for health visiting, district nursing, practice nursing and school nursing), local CHC manager, health authority primary care director, practice manager lead for training and development, the quality effectiveness and development manager, PCG executive nurse representative, and clinical governance lead (chair).

Step 3

Service review meeting

A joint meeting of local primary and secondary care health professionals, incorporating a mixture of clinical, administrative and audit experience and skills, supported by input from other groups including the health authority and the Community Health Council.

Local secondary care lead clinicians in the service area to act as the specialist resource within the meeting.

Format of the meeting

  • Overview of guidance
  • Current situation
  • Draft proposals (developed by project team)
  • Group work
  • Feedback from above
  • Achieve consensus view
  • Action plan
  • Agreed review date

Objectives of the meeting

  • Communication of guidance/draft proposals
  • Ownership of initiative
  • Communication and implementation of action plan

* Agreed local standard of care which reflects the current national and local perspective, and which looks to utilise primary and secondary care effectively and appropriately by the development of a shared care pathway

The process was well supported by the Community Health Council (CHC), which is an active member of the Clinical Governance Committee and also took an active part in the service review meetings. In the future, we hope to involve a wider group of users, particularly at the stage of developing the draft proposals.

Initial service review meeting

The meeting was held in April 1999 and was attended by more than 60 health professionals, including 34 GPs, two breast surgeons and the local oncologist. There was good attendance from clinical, administrative and support staff including audit.

The following aspects were reviewed:

  • Latest guidance
  • Proposed new guidelines
  • Proposed referral proforma
  • Referral process (24-hour rule)
  • Managing the demand
  • Management of patients with significant family history
  • Role of mammography
  • Follow-up of treated patients with breast cancer
  • Audit.


Knowledge of Calman–Hine guidance within primary care at this stage was poor. A mechanism for simplifying the guidance, so that the key features could be effectively communicated to primary care, was needed.

Minor alterations to both the guidelines and referral proforma were suggested, but they were otherwise strongly supported.

Patients with treated breast cancer should be followed up within primary care, adopting a shared care approach.

Given the current guidance and evidence available, it was decided to withdraw open-access mammography for primary care as an assessment in isolation for patients with suspected breast pathology.

An action plan based on these conclusions was then drawn up.

Action plan

  • Guidelines adopted by those present at the initial service review meeting to become standard practice for the local health community.
  • All GPs to be encouraged to use referral proforma.
  • Open access mammography for primary care to be withdrawn.
  • Follow-up of treated breast cancer patients within primary care to be considered once the initial guidelines and proforma have been road tested.
  • Initiative to be reviewed with an update meeting in approximately 6 months, which would be supported by an audit of the management guidelines.

Service review update meeting

The update meeting was held in December 1999, and was attended by more than 50 health professionals.

The following aspects of the guidelines were reviewed:

  • Are they helpful?
  • Are we following them?
  • Are we meeting the 2-week rule?

A proposal for shared care arrangements, i.e. to follow up treated patients with breast cancer within primary care, was also discussed.


The consensus of the workshop feedback was that the referral proforma and guidelines in their current form (Figures 2 & 3, below) were both helpful and supported the service development.

Figure 2: NE Lincs proforma for referral to the breast clinic
patient referral form


Figure 3: NE Lincs NHS Trust referral guidelines
referral guidelines

The audit (Figures 4a & 5) showed good utilisation of the referral proforma and guidelines, and good progress by the local breast unit towards achieving the national targets for urgent and routine referrals (Figure 4b).

Figures 4a (top) and 4b (bottom): Audit results for the first 6 months of the new guidelines (first 3 months' figures were presented at breast service review meeting in December 1999)
audit results graph
audit results graph


Figure 5: Standards for the audit
  • 95% of referrals to be made on standard patient referral form.
  • 95% of referrals to have correct demographic details, i.e. correct name and address.
  • 95% of referrals to have an accurate date of birth recorded.
  • 95% of referrals to have a daytime telephone contact number.
  • 95% of referrals to indicate whether referrals urgent or routine.
  • 100% of referrals should be dated.
  • 100% of urgent referrals to have at least one of the following recorded
    as present on the referral form/letter: breast lump, bloodstained nipple
    discharge, recent nipple retraction, peau d'orange (eczema).
  • 70% of referrals for urgent cases should be faxed.
  • 100% of urgent referrals to be received within the trust 24 hours following the decision to refer by the GP.
  • 95% of urgent cases to be seen within 14 days of the date of the decision to refer.
  • 95% of routine referrals to be seen within 6 weeks of the date of decision to refer.

It is important to review the quality of the local service annually by monitoring referrals that are not dealt with by the urgent mechanism as currently outlined (Figure 6, below).

Figure 6: Review of urgent referrals
100% of urgent referrals to have at least one of the following recorded as present on the referral form/letter: breast lump; bloodstained nipple discharge; recent nipple retraction; peau d'orange (eczema)
  • 291 urgent referrals
  • 251 (86%) mentioned the presence of 1 or more symptom

    (1 July - 31 December 1999)

graph showing number of referrals

Significant event analysis should be developed to support the above. Within this process we should look to a positive (no blame) environment where it is possible to review the referral process and consider how it should be adapted to support the further development of the service.

The proposal for follow-up of treated patients within primary care should be developed.

Within the Clinical Development initiative, 99% of GPs signed up to the guidelines and appropriate monitoring of this service (Figure 4b).

Action plan

  • Ongoing use of referral guideline, ith the referral proforma now adopted as a standard mechanism of referral to the local breast service
  • Project team identified to take forward a proposal of follow-up of treated patients with breast cancer within primary care
  • Ongoing audit to review the service development
  • Creation of significant event analysis within an appropriate environment
  • Next service review is April 2001.

A similar process was used to develop local guidelines for referral of patients with suspected colorectal cancer, and to review the local colorectal cancer service. Further details can be obtained from the author (Dr Paul Twomey, Scartho Medical Centre, 26 Waltham Road, Scartho, Grimsby, NE Lincs, DN33 2QA).

Further work on the framework has allowed appropriate development of the follow-up of patients with treated breast and colorectal cancer within primary care. It is proposed that such patients be followed up by their GP, thus promoting treatment of the patient as a 'whole' and facilitating access for patients who are concerned that their cancer may have recurred.

A local review of the breast service has shown that the vast majority of recurrences occur outside routine follow-up appointments. For the minority of patients shown to have recurrence at a follow-up appointment, further enquiry reveals that the patients were aware of a problem but waited for the forthcoming appointment to raise their concerns.

We are hoping to implement this development in the near future with the support of the CHC.

Although the Calman-Hine guidance has been centrally imposed and reflects a limited evidence base (particularly concerning the 2-week rule), it has provided a stimulus for working in partnership with our local acute trust.

The main role of the PCG management structure in the initiative has been that of a catalyst within the local health community to:

  • Disseminate the guidance and the proposed (draft) local response
  • Promote ownership of the initiative
  • Disseminate and implement the action plan
  • Facilitate appropriate review.

The systems developed for breast and colorectal cancer will aid the development of other cancer areas as well as other service areas.

The work undertaken within the initiative has been significant, particularly given the capacity of the PCG structure. This is also within an environment in which the new PCT (upgraded from PCG in April 2000) is juggling an ever-wider range of challenges.

For the future, it is important that good practice is shared to enable the most effective implementation of guidance. It may also be appropriate for the PCT to focus and maximise its efforts on guidance and areas in which it can make a significant clinical difference or which are currently a particular local focus.

  • The success to date of this initiative has principally been due to the wide involvement of health professionals, both clinical and administrative. It is appropriate to acknowledge the key input of specific individuals including our local breast and colorectal surgeons, Mr L Donaldson and Mr H Pearson. Our local Quality Effectiveness and Development Department, led by Sarah Johnstone, in collaboration with The Diana, Princess of Wales, Audit Department, has provided the principal administrative support.

Guidelines in Practice, November 2000, Volume 3
© 2000 MGP Ltd
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